Management of Intraoperative Crisis During Nonintubated Thoracic Surgery

Nonintubated video-assisted thoracoscopic surgery programs have gradually spread all over the world. The benefits are based on less invasiveness and earlier recovery. However, complications may appear. For the correct prevention and management of all these potentially critical situations, the principles of crisis resource management (CRM) must be followed. They should also include clinical simulation as a tool to generate different scenarios to improve teamwork. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery, including the management of specific surgical and medical critical scenarios.

Key points

  • The benefits of nontubated video-assited thoracoscopic surgery are based on the less invasiveness and earlier recovery. But nevertheless, intraoperative complicactions are possible.

  • Correct prevention and management of these potentially critical situations are vital, and the principles of crisis resource management must be followed.

  • Crisis resource management must include clinical simulation as a tool to generate different scenarios to improve teamwork.

  • Simulation-based crisis resource management training programs for a specific surgery can contribute to reduce frequency and effect of these critical situations.


In recent years, different nonintubated video-assisted thoracoscopic surgery (NIVATS) programs with different degrees of complexity have been developed, based on less invasiveness and early recovery, compared with standard surgery. The theoretic benefits are obvious: avoid orotracheal intubation, the adverse effects of using double-lumen tubes, open pneumothorax with better lung collapse, and caudal movement of the diaphragm. There is also a less immunologic and inflammatory impact and even in morbidity and hospital stay. Potential risks include hypoxemia, hypercapnia, cough, and severe bleeding. These complications can evolve into a critical situation in which trained personnel is essential.

Intraoperative surgical emergencies are included in the high acuity (it assesses the severity of an event and the impact on the patient) and low occurrence (it assess the occurring frequency). This combination puts the patient in a situation in which medical errors can occur more commonly. Although these errors are ubiquitous and unavoidable, one must try to establish the knowledge, skills, and attitudes necessary to achieve proper teamwork and systematically guide the management of a critical event. This strategy would probably reduce the incidence of errors and improve decision making.

A strategy for handling these situations comes from the application of the principles of crisis resource management (CRM). CRM tries to develop all the nontechnical skills needed in a critical situation, but not only that, it also includes all the tools necessary to prevent it. Can the risks be reduced with an adequate training plan? That is what this article is going to try to answer.

Crisis resource management key elements applied to nonintubated video-assisted thoracoscopic surgery

Managing critical events during surgery is one of the most difficult and important tasks required of the surgical team. It was Professor Gaba, more than 20 years ago, who introduced the concept of CRM. CRM refers to the set of nontechnical skills required for effective teamwork in a crisis situation, whereby patient safety during surgery is the main objective. The CRM concept was originally developed in the aviation domain. It was initially called “cabin resource management” and later “crew resource management,” because of the importance of the group’s reaction in a crisis by simulating different scenarios. The key elements of CRM are listed in Table 1 .

Table 1

Crisis resource management key elements and nonintubated video-assisted thoracoscopic surgery application

CRM Key Elements NIVATS Application

  • 1.

    Know the environment and available resources

  • 2.

    Anticipation and plan

  • 3.

    Call for help soon

  • 4.

    Exercise leadership and “followship”

  • 5.

    Distribute workload

  • 6.

    Mobilize all available resources

  • 7.

    Communicate effectively

  • 8.

    Use all available information

  • 9.

    Prevent and manage fixation errors

  • 10.

    Double and cross-check

  • 11.

    Use cognitive aids

  • 12.

    Reevaluate repeatedly

  • 13.

    Good teamwork

  • 14.

    Focus attention wisely

  • 15.

    Set priorities dynamically

  • Expert team (>50 VATS cases)

  • Anesthesiologist trained in the lateral position

  • First case of the day

  • Emergency table prepared

  • Specific informed consent signed by the patient

  • At the beginning of the NIVATS program, 2 anesthesiologists in the operation room

  • In case of surgical crisis (bleeding), one of the nurses helps the surgeon, if it is medical (hypoxemia), the nurse helps the anesthesiologist

  • Specific cognitive aids developed for NIVATS (anestCRITIC)

  • Use high-fidelity simulators to train: hypoxemia (lateral intubation), severe bleeding (reconversion to thoracotomy), and cardiac arrest in the lateral position

Know the Environment and Available Resources

One of the key elements is to try to prevent the complication from happening. For that reason, knowing your environment and all the available resources is essential. This first set of CRM actions can be called “ before the crisis happens. ” The available resources can be classified as human (one’s own knowledge/skills and the others around him or her), materials, cognitive aids, and other external resources. The human performance resources are not constant throughout the day, because they are affected by fatigue, need of sleep, emotional disturbances, health problems, lack of experience, welfare pressure, and lack of knowledge. From these circumstances, the dangerous attitudes of oneself or one’s environment are especially important, examples such as antiauthority, “Don’t tell me what to do!”; impulsivity, “Do something quickly”; invulnerability, “That would never happen to me”; macho, “You’ll see how I operate it”; resignation, “There’s nothing we can do.” For these attitudes, antidotes must be found, and, in some cases, a psychologist may even have to be consulted. A second important aspect is the pressure to which the surgical staff is subjected. To control this, multidisciplinary protocols must be approved by all parties involved, in which the day-to-day surgery adapts based on the needs of patients (safety) and not the numbers to be met. Along with that, it is essential to check the correct functioning of the available material resources before starting (how each element works as well as the most frequent faults), making sure that the emergency equipment is immediately available. Other external resources include “who” can be asked for help in an emergency and “where” the things are that are needed.

The NIVATS team must know their own limitations, try to improve them, and have previous experience. To define experienced team, the following criteria are used: surgeons, anesthesiologists and nurses must have done more than 50 conventional VATS and overcome the learning curve along with experience in difficult cases of large pulmonary resections (large and central tumors, bronchoangioplasties, tumors with invasion of neighboring structures). In addition, they should have faced complications, such as moderate or severe bleeding through VATS. A unique issue is that the anesthesiologist must be trained in the lateral intubation. The authors discuss it in more detail in later discussion. The NIVATS patient, at the beginning of the program, should be scheduled as the first case of the day. The surgical equipment the authors use is the standard VATS. What is different is that they have prepared what they call the “emergency table” ( Box 1 ). It is essential that everything is reviewed and prepared.

Box 1

Checklist in nonintubated video-assisted thoracoscopic surgery

  • Before surgery

    • Consent to anesthesia and specific surgery for this procedure

    • World Health Organization safety list

    • Two anesthesiologists present

  • Emergency table

  • Anesthesia

    • Facial mask of the size adapted to the patient

    • Guedel cannula

    • Laryngoscope with 2 blade sizes

    • Videolaryngoscope (in the authors’ case, the double lumen tube Airtraq)

    • Two sizes of double lumen tube (35–37F) orotracheal tubes

    • Two sizes of single tracheal tubes (7–7.5 mm)

    • Endobronchial blocker (in the authors’ case, Uniblocker)

    • Frova Guide

    • Fibrobronchoscope ready to use (3.7 mm)

    • Drugs for the induction of a general anesthetic (propofol + fentanyl + rocuronium)

    • Drugs for reversal of muscle relaxant (Sugammadex)

  • On the instrumentalist table, there will be the following:

    • Thoracic drainage (24F)

    • Drainage system with water seal, ready to use

Anticipation and Plan

In order to try to avoid patient-related problems, a strict inclusion protocol is applied (included in a checklist). The surgeon and anesthesiologist explain the advantages and disadvantages of NIVATS to the patient, and a specific informed consent is signed. In case of doubt, the patient is excluded. Anticipation helps to avoid surprises because during a crisis surprises are not welcome. Planning ahead eliminates much of the stress in those times of great upheaval. One must to try to wait for the unexpected, and as a pilot would say, “always fly in front of our plane.”

Call for Help Soon

Asking for help early is not a sign of lack of self-confidence but demonstrates your respect and sense of responsibility for your patient’s safety. Heroes are dangerous. We need to know what kind of help is needed: muscle, transportation, general technical skill, knowledge, or just someone trustworthy. At the beginning of the NIVATS program, the authors had 2 anesthesiologists in the theater, and after gaining experience, at least 1 expert colleague is located in the surgical area. Calling for help is very important to avoid fixing errors in the event of a crisis.

Exercise Leadership and Followers

The first objective is to define the role and functions of the team , knowing when to be a leader (leadership) and when to be a follower (“followship”). The leader has to communicate effectively, without raising his voice, indicating orders or needs in the clearest and most precise way possible, avoiding making statements on the air, asking for the confirmation message when something or someone is asked for. The follower must listen to what the leader says and do what is needed always with an open mind to help and convey their concerns to the leader. The focus must be what is right and not who is right. In case of a surgical emergency (severe bleeding), with the patient stable, the leader is the surgeon. If it is a medical emergency (hypoxemia), the anesthesiologist takes control of the situation and should stop the surgery if deemed necessary. Knowing the type of emergency is important for allocating other human resources (nursing). At the beginning of an NIVATS, the authors have 3 nurses in the operating room. In case of emergency, 1 nurse assists the surgeon, and the other assists the anesthesiologist. In the authors’ hospital, they do not have specific anesthesia nurses, which would be ideal.

Distribute the Workload

One of the main tasks of the leader is to distribute the workload. Someone has to define the tasks, check that they are carried out correctly, and check that everything is working properly. If possible, the leader should be freed from other tasks to observe, gather information, and delegate. Team members should actively seek out all those tasks that need to be done. It is not a good team in which its leader has to direct each of its actions.

Mobilize All Available Resources

In order to handle a problem, one should think of everyone and everything that could help to handle the problem. That includes people and technology. As far as the human aspect is concerned, their knowledge and skills as well as knowing their strengths and weaknesses are their most important resources. The resources are there to be used. After a crisis, one often realizes that there were precious resources available that should have been mobilized. They can be human or monitoring and equipment.

Communicate Effectively

Communication is the key in crisis situations. Communication ensures that everyone knows what is going on, what needs to be done, and what is already done, which sometimes is hard. The fact of saying something can be considered a communication if the message is received. Meaning does not mean “to say,” saying does not mean “to hear,” hearing does not mean “to understand,” and understanding does not mean “to do.”

Use All Available Information

Medicine is complex because information must be integrated from many different sources. Each piece of information can help one better understand the patient’s condition to arrive at a correct diagnosis. Complete the scheme by correlating all the different sources: clinical impression, information from relatives (eg, drug abuse or coexisting diseases), and above all, watch for changes in vital signs.

Prevent and Manage Fixation Errors

The next point to develop is the so-called fixing errors. This type of error is very common in dynamic settings and creates a persistent inability to review a diagnosis or plan even though the available evidence suggests that review of the diagnosis or plan is necessary. The 3 most common are the following situations: “It is this and only this,” we have not taken into account an alternative diagnosis; “Everything but this,” neglecting a single diagnosis; “Everything is fine,” they do not recognize the need to act in emergency mode. One must try to avoid these errors by checking and rechecking from the outset all the actions that are carried out, even if it is thought that it has been done correctly. Crisis situations are dynamic: what is right now may be wrong the next minute. Fixation errors are errors of the mental model one has of both the patient and the situation. They are therefore difficult to grasp and are presented in a variety of ways. Knowing the enemy helps to answer him. Always rule out the worst-case scenario.

Double and Cross-Check

Cross-checking means correlating data from different sources. Is the artifact seen in the electrocardiogram also seen in the pulse oximeter wave? Memory sometimes deceives and always tries to make things fit together in a logical way. It might not be an artifact. Double-checking is about making sure that what you remember you saw is what you actually saw. As has been said before, sometimes the mind deceives us and you think you did something, but you may not have done it, simply because you thought of doing it but you did not do it. You may have thought of suspending a perfusion, but it turns out that you left it completely open. Check all devices to make sure they are the way you want them to be.

Use Cognitive Aids

It is recommended to use cognitive aids. There are different types of cognitive aids (checklist vs lineal vs branched algorithms), but they all have similar functions. The great strength of humans (but also their great weakness) lies in the fact that they tend to take shortcuts, do not think systematically, and are flexible. What, in general, is a help, will cause mistakes when things have to be done in a clear order and without losing any element. That is why humans design cars and robots and make them by following the same pattern over and over again. Using checklists, which are common in other fields, can help one not to forget important steps in diagnosis or treatment. If machines are better than humans in math, why not let them be? Calculating doses using a calculator leads to fewer errors than doing so using one’s head. Searching for doses or other information demonstrates responsibility and not lack of knowledge. Never feel bad about looking for something, even if you knew it before and do not remember it anymore. Keep important information in a safe place. Do not be a hero; be responsible. It could be a life or death decision!

A checklist described in Box 1 is used, where all items must be marked for an NIVATS. Along with this it should be available a cognitive aid either on paper or in an electronic version (anestCRITIC, available in iTunes and Google Play).

Reevaluate Repeatedly

Medicine is dynamic. What is right now may not be right in the next minute. Each piece of information can be important and can change the situation. Although some parameters may change slowly over time, subtle changes can be difficult to perceive. Do not hesitate to follow a dynamic situation by making decisions dynamically (do not go on with the decisions you made if the situation changes).

Good Teamwork

Not all teamwork is good, and getting good teamwork is difficult. The coordination of a team begins before it is assembled. If all members know the work to be done and their roles within this work, coordination is easier. To this end, several meetings have been held before the start of the project ( Fig. 1 ), including clinical simulations using high-fidelity simulators. Respect team members and their “weaknesses.” The “players” of the team must be attentive to the needs of the people next to them. Work hand in hand.

Aug 16, 2020 | Posted by in CARDIAC SURGERY | Comments Off on Management of Intraoperative Crisis During Nonintubated Thoracic Surgery
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